Provider Demographics
NPI:1043794407
Name:SHAH, CHINTAN PRAGNESH (PT,DPT)
Entity Type:Individual
Prefix:
First Name:CHINTAN
Middle Name:PRAGNESH
Last Name:SHAH
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE COMO
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3097
Mailing Address - Country:US
Mailing Address - Phone:732-894-9200
Mailing Address - Fax:732-894-9202
Practice Address - Street 1:1719 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE COMO
Practice Address - State:NJ
Practice Address - Zip Code:07719-3097
Practice Address - Country:US
Practice Address - Phone:732-894-9200
Practice Address - Fax:732-894-9202
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01823200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01823200OtherNJ PT LICENSE